Provider Demographics
NPI:1205964103
Name:FULLERTON KIMBALL MEDICAL & SURGICAL CENTER
Entity type:Organization
Organization Name:FULLERTON KIMBALL MEDICAL & SURGICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RENLIN
Authorized Official - Middle Name:
Authorized Official - Last Name:XIA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-235-8000
Mailing Address - Street 1:3412 W FULLERTON AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60647-2416
Mailing Address - Country:US
Mailing Address - Phone:773-235-8000
Mailing Address - Fax:
Practice Address - Street 1:3412 W FULLERTON AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60647-2416
Practice Address - Country:US
Practice Address - Phone:773-235-8000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-01
Last Update Date:2014-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL7003181261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL261Q00000XOtherTAXONOMY CODE
IL141064Medicare ID - Type Unspecified